Frequently Asked Questions

Yes. Responding to direct questions from consumers is not generally a violation of 42 CFR 438.104. Proactive consumer inquiries to a health plan for information about coverage options, benefits, or provider networks is no different than a consumer obtaining information from the health plan's website. So long as the limits on marketing are satisfied and respected (e.g., the information is accurate and does not mislead, confuse or defraud beneficiaries or the state Medicaid agency), responding to direct questions from potential enrollees with accurate information is not prohibited.

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FAQ ID:94391

There is no provision in 42 CFR 438.104 specifically addressing a Medicaid managed care plan's outreach to enrollees for eligibility purposes; therefore, it depends on the Medicaid managed care plan's contract with the state Medicaid agency. The federal regulation at 42 CFR 438.104 defines marketing as ""any communication, from an [Medicaid managed care plan] to a Medicaid beneficiary who is not enrolled in that entity, that can reasonably be interpreted as intended to influence the beneficiary to enroll in that particular [Medicaid managed care plan's] Medicaid product, or either to not enroll in, or to disenroll from, another [Medicaid managed care plan's] Medicaid product."" So long as information and outreach about the eligibility renewal process is neither directed to beneficiaries who are not enrolled with that Medicaid managed care plan, nor intended to influence the beneficiary to enroll in that particular Medicaid managed care plan-or to not enroll in, or disenroll from another Medicaid managed care plan-the activity is not within the scope of 42 CFR 438.104. Materials and information that purely educate an enrollee of that Medicaid managed care plan on the importance of completing the State's Medicaid eligibility renewal process in a timely fashion would not meet the federal definition of marketing. However, Medicaid managed care plans should consult their contracts and the state Medicaid agency to ascertain if other provisions exist that may prohibit or limit such activity.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 138.58 KB)

FAQ ID:94396

States wishing to continue the practice of disregarding parental income may do so by adopting coverage of a reasonable classification of individuals under age 21 under section 42 CFR 435.222. In this case, the "reasonable classification" would be pregnant individuals under age 21 (or under age 18, 19, or 20). The statutory income standard for this group would be based on the state's AFDC payment standard in effect in the state in July 1996. But if a state uses section 1902(r)(2) of the Act to disregard all income for this group, as has been done for other reasonable classifications of children (such as those in state foster care), there will be no determination of income required for eligibility, and MAGI-based income requirements will not apply.

To effectuate this option, states should submit a state plan amendment (SPA) to amend Attachment 2.2-A of the Medicaid state plan to cover a reasonable classification of pregnant individuals under age 21 under 42 CFR 435.222. The state should also amend Supplement 8a to Attachment 2.6-A to disregard all income for this new group.

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FAQ ID:92601